Optic neuritis after mRNA COVID‐19 vaccination: a case report

Key Clinical Message Our case reported a 22‐year‐old male presented with headache, and sudden vision loss, 10 days after receiving the first dose of COVID‐19 vaccination. Counting fingers in both eyes was his visual acuity on examination and bilateral optic disc edema on fundoscopy was found. Brain MRI was normal. After methylprednisolone pulse therapy, plasmapheresis, and IV cyclophosphamide courses, the optic disc edema disappeared, and his visual function did not improve. Reported cases of optic neuritis develop after mRNA COVID‐19 vaccination are limited.

anti-phospholipid antibodies, C-ANCA, P-ANCA, and IgG4 was negative.Anti-aquaporin 4 antibody and anti-myelin oligodendrocyte glycoprotein antibody were also negatives.Cerebral spinal fluid analysis was normal.
Brain magnetic resonance imaging and magnetic resonance vein were normal, and no findings suggestive of demyelinating disease or compressive lesions were found (Figure 5).
Optic nerve MRI was normal.
Neck, thoracic, abdominal, and pelvic CT scans were normal.
He was treated with 1000 mg/IV/day methylprednisolone for 5 days followed by 70 mg/day oral prednisolone.Ophthalmological examination showed that disappearing of the bilateral optic disc swelling, without any improvement of visual capacity.The headache disappeared.
Another course of methylprednisolone pulse therapy for 5 days and 750 mg/IV/M2 cyclophosphamide every 15 days had been initiated, in addition to five courses of plasmapheresis.His visual function showed no improvement after the six doses of cyclophosphamide and 60 mg/ day prednisone.

| DISCUSSION
Many complications following vaccination including ocular manifestations had been seen.Uveitis, vision loss, papilledema, central serous retinopathy, central retinal vein occlusion, and others have been reported. 4,5ON after vaccination against influenza, polio, hepatitis B, diphtheria, tetanus, and others giving rise to permanent visual loss in some cases has also been mentioned. 3,6olecular mimicry, superantigen stimulation, and bystander activation may play a role in the development of demyelinating lesions of the nervous systems. 7Immune complex may cause vascular damage, leading to perivascular inflammation, vascular permeability, and blood-brain barrier disruption, and the last event allows antibodies to enter the brain causing demyelination. 8he mechanism of ON following mRNA vaccination is still unclear.Increased serum cortisol, free extracellular mRNA, and polyethylene glycol may be the cause. 4,9ere, an autoimmune response leading to bilateral ON was triggered by mRNA COVID-19 vaccination, while it is difficult to prove the association with the causation of vaccines. 2,3,6,7I G U R E 1 Ophthalmological examination revealed counting fingers in both eyes.
Critical visual loss occurs suddenly with pain, and only 0.4% of patients develop symptoms in both eyes simultaneously, 5,7,9 as in our case.VEP studied the visual function, and magnetic resonance imaging considered as a sensitive indicator of demyelination in ON, 10,11 as in our patient.
A Cochrane review evaluating the beneficial effects of corticosteroids in terms of visual recovery, and visual field.
When these patients had poor response to steroids, immunotherapy, plasmapheresis, or intravenous immunoglobulin should be initiated at the earliest. 4,5,7he long-term visual outcome of ON is good, although one in three patients remains visually impaired, and this is usually accompanied by more extensive lesions on magnetic resonance imaging and lower levels of VEP. 4,5,7In our case, the prognosis was very poor ended with blindness even there were no extensive lesions on magnetic resonance imaging.

| CONCLUSION
Optic neuritis following COVID-19 vaccination against rarely reported in the literature.Only a total of 8 reports on 9 patients have been published to date, 8 of 9 were females. 5,7,9,11Our case is the third case of post-COVID-19 vaccination optic neuropathy in a male.The cases affect young females more, with improvement with IV methylprednisolone therapy for most of them, after 6-14 days after the COVID-19 vaccination; meanwhile, our patient is a male who developed ON after 10 days of vaccination and did not respond to IV methylprednisolone therapy.
In conclusion, several cases of optic neuropathy have been reported, with good prognoses with treatments.Additional studies are recommended.

F I G U R E 2
Visual field imaging (right eye).